Last Hope for German Liberals? A Vietnamese-Born Doctor

 

ROSTOCK, GERMANY — A young Vietnamese-born physician has become the German liberals’ last hope for defending their standing in the government and preparing for the next federal elections, set to take place in 2013.

The politician, Philipp R?sler, 38, who was elected leader of the Free Democrats last week with overwhelming support, promised a new beginning during a packed party congress in Rostock during the weekend, a rallying cry for a party that has plummeted in opinion polls ever since joining Chancellor Angela Merkel’s center-right coalition 18 months ago.

“From today, the F.D.P. will deliver,” he told delegates Saturday, trying to salve wounds suffered during recent defeats in regional elections.

Mr. R?sler also became economy minister when he assumed the party leadership from Guido Westerwelle, who will remain in the government as foreign minister but gave up all Free Democrat duties.

But if Mr. R?sler wants to sharpen the profile of the party, he is likely to run into conflict with the conservative bloc of Mrs. Merkel. And while a stronger and more popular Free Democratic Party would undoubtedly help the government in the opinion polls, it could also create a more fractious coalition.

During his speech, Mr. R?sler promised that the party would defend what had always been the heart of its philosophy: civil rights. This is bound to lead to conflicts with the Christian Social Union, the sister party of Mrs. Merkel’s Christian Democrats.

Since taking office three months ago, Interior Minister Hans-Peter Friedrich, a Christian Socialist, has called for tighter controls over the Internet and more powers for security services to prevent terrorist attacks and combat crime.

While the Free Democrats had always raised some opposition to such controls, those objections were often less than forceful under Mr. Westerwelle.

On his watch, the party became so focused on a single issue — tax cuts — that when he failed to persuade the Christian Democrats to go along with an overhaul of the tax system, he lost significant support.

When it became clear that Mr. R?sler, who until last week held the post of health minister, would assume the party leadership, he reassigned the Free Democrats’ top jobs, giving himself the far more popular job of economics minister.

Mr. R?sler made it clear that the party would still fight for tax reform. “We are willing to do it,” he told the congress on Saturday. “We are just waiting for our coalition partners.”

But in a major policy change, he also said the Free Democrats would support Finance Minister Wolfgang Sch?uble’s goal of cutting the budget deficit.

And in another sign that Mr. Sch?uble will find a more willing ally in Mr. R?sler, the new party leader quashed attempts by a group of euro-skeptic Free Democratic federal lawmakers to oppose an economic rescue package from the European Union and the International Monetary Fund.

On Monday and Tuesday, E.U. finance ministers are expected to approve a €78 billion, or $110 billion, bailout for Portugal. And in September, the German Parliament must vote on the final €700 billion package for debt-ridden countries in the bloc.

Mr. R?sler said the party had to reach out to “normal people,” phrasing that analysts said was an attempt to shed the Free Democrats’ image as a well-to-do movement detached from social problems.

Indeed, Mr. R?sler, a father of 2-year-old twins, spoke about single working parents struggling to find all-day child-care centers or schools, and families struggling to meet the costs of looking after their aging parents.

Mr. R?sler lived in a Roman Catholic orphanage in Saigon until being adopted by a German couple when he was 9 months old.

He has said in interviews that he had a normal German upbringing, growing up with his father, a career soldier, when his adoptive parents separated. He studied medicine and worked full time as an army doctor until 2003.

He also rose steadily through the ranks of the Free Democratic Party, which he joined when he was 19.

 

Well: Should Your Doctor Be on Facebook?

 Nicolas Loran/Getty

When I was a third-year medical resident, an attending physician handed me his business card so that I could contact him about a patient. Printed below his phone number was something I hadn’t seen on a business card before: an e-mail address.

I thought to myself, “How pretentious!”

It’s hard to believe this occurred less than 20 years ago. Now most of my house staff wince when I suggest communicating by e-mail. E-mail is for old fogies, they imply with their body language. They prefer to text or send instant messages in the hospital, and use Facebook or Twitter with friends.

For doctors like me who have waded into social media, however gingerly, many questions arise. Is posting a medical musing or details of a recent party on Twitter or Facebook the same as chatting with colleagues while walking down the hall of the hospital? Do the same rules of etiquette and liability apply to this extremely public environment?

An article in The Journal of General Internal Medicine highlights some of the hazards of the murky mixing of personal and professional selves that occurs in the online world. In one example, a doctor had posted photos of himself and his colleagues partying on his Facebook page. These were aid doctors providing medical care in Haiti, and the unprofessional images of drinking, carousing and posing with guns cast a poor light on what by all accounts was exemplary medical work.

The article notes how the online world facilitates “disinhibition” and how a momentary lapse can be rapidly magnified and become permanently embedded in the cyberworld. Rapid dissemination, downloading and reposting make it nigh impossible to scrub unwanted images and text from the Web. Dr. Ryan Greysen, the lead author and a Robert Wood Johnson Foundation clinical scholar at Yale School of Medicine, endorses a “think before you post” philosophy, keeping in mind that you can never tell what a friend’s friend’s friend might do with a photo, video or nugget of information.

“Think about your digital footprint,” Dr. Greysen says, “but also think more broadly. How would hundreds of posts like this reflect on the profession?”

He also notes that “violations of professionalism online are no different than violations in ‘real life’ and could be sanctioned by state medical boards.” A major concern, he says, is with the new generation of physicians and students who enter the medical world after years of saturation in social media.

Dr. Kevin Pho, a primary care doctor in New Hampshire who writes the popular KevinMD blog, maintains both a personal and a professional online presence. His professional Facebook page contains his writing and commentary and can be “liked” by anyone. He limits access to his personal Facebook page to family and close friends.

I worry that it is impossible to maintain a perfect firewall, so I’ve decided to limit my online presence to the professional side of my life, keeping personal information off the Web. And before I post anything anywhere, I try to imagine what a patient of mine might think if she stumbled across it. Would it make her cringe? Would she feel awkward during her next office visit? Would this somehow compromise our relationship?

This means letting go of the fun and casual side of social media, but I think that’s simply part of the territory of being a doctor. It’s the same reason I don’t wear flip-flops and shorts to work, much as I’d surely love to. Giving up posting vacation pictures doesn’t seem like a particularly high price.

Doctors — like everyone else — are entitled to private lives, with all the attendant warts, embarrassments and unflattering moments. But now that any patient can Google a medical team, doctors — like teachers and lawyers — need to consider issues of professionalism before sharing their private lives.

But social media has its upside, too. As Dr. Pho points out, social media “can be an effective tool to guide patients to reputable sources of information,” countering the deluge of health information on the Internet. The Web likewise holds the promise of expanding accessible channels of communication between doctors and patients, though the complexities and liabilities certainly need to be ironed out.

I’m sure there are those who view a doctor with a Twitter account as pretentious, just as I viewed my own attending 20 years ago with his flashy e-mail address. But the iterations of online technology are likely to mutate faster than our staid medical institutions can adapt. In a few years these same doctors who have embraced Twitter may be seen as hopeless Luddites. The next generation of medical students will look at us with a collective eye-roll, unable to believe that we could persist in something so artless and archaic.

Dr. Danielle Ofri is an internist at Bellevue Hospital in New York City and editor in chief of the Bellevue Literary Review. Her most recent book, “Medicine in Translation: Journeys With My Patients,” is about the care of immigrants and Americans in the United States health care system.

 

Doctor Focuses on the Minds of the Elderly

 

The guest of honor and her two friends were beaming when Dr. Marc E. Agronin, a geriatric psychiatrist and the director of mental health, arrived with a hug for everyone long after what would be normal office hours.

The Merry Widows moved to the community when their husbands developed Alzheimer’s disease and looked to Dr. Agronin to prepare them for what lay ahead. But while treating their husbands’ disease, he became their psychiatrist, too. He urged the women to attend therapy groups, made suggestions about medication for anxiety and encouraged new bonds of friendship.

Dr. Agronin calls them his graduates — a trio of success stories among 3,700 patients he is responsible for, in what, by all accounts, is the largest geriatric psychiatry practice in the nation, at the Miami Jewish Health Systems.

The doctor is a rare breed even in Florida, which has the highest proportion of people older than 65. There are only 17 board-certified geriatric psychiatrists in the state, and a mere six here in southeast Florida, where snowbirds from New York often come to perch. In March, acknowledging the crisis in care, the federal Institute of Medicine began a study of the shortage of geriatric mental health workers nationwide.

Dr. Agronin, 45, is unusual not just because of his specialty but because he is a salaried staff member immersed in the fabric of life for patients and caregivers. Residents in most senior facilities must await a shifting cast of mental health professionals, who are available — even for a prescription — only one or two days a week or in an emergency.

Now, a growing number of experts are calling for integrating mental health professionals into all levels of communities for the rising population of aging Americans, from nursing homes to assisted-living centers.

Gary Kennedy, the director of geriatric psychiatry at Montefiore Medical Center in the Bronx, says psychological care is “equally if not more important than” medical care for this group. “Health policy continues to lag behind the reality that these are now mental health facilities,” Dr. Kennedy said of communities for the elderly.

While Alzheimer’s receives the lion’s share of public attention, garden-variety depression, anxiety and sleep disorders also accompany old age. Particularly for late-life depression, Dr. Agronin points to data assembled by the psychiatry department at the University of California, San Francisco, supporting behavioral and group therapy, treatment rarely tried with patients from generations typically considered averse to discussing such issues.

But treatment that focuses on talking, rather than on medical procedures, has a lower Medicare reimbursement rate. The economic difficulties may explain why more doctors have not entered the time-intensive field.

“Approximating what I do is hardly economically feasible,” said Dr. Agronin, the author of “How We Age.” “Caregivers need assessment and services as well, and this is not reimbursable time.”

For Dr. Agronin, and for the social worker and the psychologist who work with him, there is no such thing as the 50-minute billing hour. Rather, on a routine day, his work is often done ad hoc as he wanders the corridors, dining rooms and garden here. He loosens the boundaries set by most schools of psychiatry, which discourage clinicians from befriending patients. Here, staff members are physically affectionate and may even give patients a personal cellphone number.

“He is a lifesaver,” Mrs. Weisburd said as Dr. Agronin helped blow out the candles on her cake. “He helps you walk down the mountain.”

The mountain is old age, with its physical and cognitive decline, its steady loss of loved ones and its inevitable outcome. Dr. Agronin says his mission is to restore dignity and hope to people who were raised at a time when mental issues were often stigmatized.

Some 700 of Dr. Agronin’s patients live on the main campus of Miami Jewish Health Systems, in independent or assisted-living apartments, a nursing home or an Alzheimer’s unit. The rest of them come to his clinic or are served by the system’s community programs throughout South Florida.

Dr. Agronin and other geriatricians find that behavioral therapy (changing the way one thinks and solving current problems) works better than analysis (excavating the past). And Dr. Agronin, who has written about some of his cases for the Science section of The New York Times, said he relied on group therapy because patients often benefit from the insights of their peers.

That was the case with Francoise Dorville, a 78-year-old Haitian immigrant who uses a wheelchair and is on dialysis and oxygen. Mr. Dorville, a widower estranged from his four surviving children, was stabilized with medication for depression and then agreed — reluctantly — to participate in a group.

Though he did not make eye contact with anyone in the group for the first month, Mr. Dorville did show up for the daily two-hour sessions. Eventually, the group persuaded him to contact his children, discussing his old-country idea that being a good father meant providing food and shelter and little else.

 

Doctor Focuses on the Minds of the Elderly

The guest of honor and her two friends were beaming when Dr. Marc E. Agronin, a geriatric psychiatrist and the director of mental health, arrived with a hug for everyone long after what would be normal office hours.

The Merry Widows moved to the community when their husbands developed Alzheimer’s disease and looked to Dr. Agronin to prepare them for what lay ahead. But while treating their husbands’ disease, he became their psychiatrist, too. He urged the women to attend therapy groups, made suggestions about medication for anxiety and encouraged new bonds of friendship.

Dr. Agronin calls them his graduates — a trio of success stories among 3,700 patients he is responsible for, in what, by all accounts, is the largest geriatric psychiatry practice in the nation, at the Miami Jewish Health Systems.

The doctor is a rare breed even in Florida, which has the highest proportion of people older than 65. There are only 17 board-certified geriatric psychiatrists in the state, and a mere six here in southeast Florida, where snowbirds from New York often come to perch. In March, acknowledging the crisis in care, the federal Institute of Medicine began a study of the shortage of geriatric mental health workers nationwide.

Dr. Agronin, 45, is unusual not just because of his specialty but because he is a salaried staff member immersed in the fabric of life for patients and caregivers. Residents in most senior facilities must await a shifting cast of mental health professionals, who are available — even for a prescription — only one or two days a week or in an emergency.

Now, a growing number of experts are calling for integrating mental health professionals into all levels of communities for the rising population of aging Americans, from nursing homes to assisted-living centers.

Gary Kennedy, the director of geriatric psychiatry at Montefiore Medical Center in the Bronx, says psychological care is “equally if not more important than” medical care for this group. “Health policy continues to lag behind the reality that these are now mental health facilities,” Dr. Kennedy said of communities for the elderly.

While Alzheimer’s receives the lion’s share of public attention, garden-variety depression, anxiety and sleep disorders also accompany old age. Particularly for late-life depression, Dr. Agronin points to data assembled by the psychiatry department at the University of California, San Francisco, supporting behavioral and group therapy, treatment rarely tried with patients from generations typically considered averse to discussing such issues.

But treatment that focuses on talking, rather than on medical procedures, has a lower Medicare reimbursement rate. The economic difficulties may explain why more doctors have not entered the time-intensive field.

“Approximating what I do is hardly economically feasible,” said Dr. Agronin, the author of “How We Age.” “Caregivers need assessment and services as well, and this is not reimbursable time.”

For Dr. Agronin, and for the social worker and the psychologist who work with him, there is no such thing as the 50-minute billing hour. Rather, on a routine day, his work is often done ad hoc as he wanders the corridors, dining rooms and garden here. He loosens the boundaries set by most schools of psychiatry, which discourage clinicians from befriending patients. Here, staff members are physically affectionate and may even give patients a personal cellphone number.

“He is a lifesaver,” Mrs. Weisburd said as Dr. Agronin helped blow out the candles on her cake. “He helps you walk down the mountain.”

The mountain is old age, with its physical and cognitive decline, its steady loss of loved ones and its inevitable outcome. Dr. Agronin says his mission is to restore dignity and hope to people who were raised at a time when mental issues were often stigmatized.

Some 700 of Dr. Agronin’s patients live on the main campus of Miami Jewish Health Systems, in independent or assisted-living apartments, a nursing home or an Alzheimer’s unit. The rest of them come to his clinic or are served by the system’s community programs throughout South Florida.

Dr. Agronin and other geriatricians find that behavioral therapy (changing the way one thinks and solving current problems) works better than analysis (excavating the past). And Dr. Agronin, who has written about some of his cases for the Science section of The New York Times, said he relied on group therapy because patients often benefit from the insights of their peers.

That was the case with Francoise Dorville, a 78-year-old Haitian immigrant who uses a wheelchair and is on dialysis and oxygen. Mr. Dorville, a widower estranged from his four surviving children, was stabilized with medication for depression and then agreed — reluctantly — to participate in a group.

Though he did not make eye contact with anyone in the group for the first month, Mr. Dorville did show up for the daily two-hour sessions. Eventually, the group persuaded him to contact his children, discussing his old-country idea that being a good father meant providing food and shelter and little else.

 

Wealth Matters: Putting Your Doctor, or a Whole Team of Them, on Retainer

With that he entered the world of concierge medicine, a growing subset of medicine where patients pay doctors anywhere from $1,500 to $25,000 a year to receive personalized attention and care. (Dr. Glazer said he was paid toward the top of this range.) In most cases, patients presume that in an emergency their concierge doctor will push them to the front of the line to see a top specialist.

Even as more people are struggling to pay medical bills and being rushed through office visits with their doctors, an elite group with money has another option: exclusive medical care, around the clock and anywhere in the world, including on a yacht or private plane.

One of Dr. Glazer’s clients, for instance, has had his yacht outfitted with a system from Guardian 24/7, a company in Leesburg, Va., founded by former White House doctors that advertises itself as offering “medical protection previously available only to the president of the United States.” The company’s “ready room” will allow a doctor trained in the system to perform basic medical care remotely if something should go wrong while the patient is on the high seas.

“There is very little that we can’t do with the triage room on their yacht,” he said.

The cost of Guardian 24/7’s services ranges from $6,000 to $12,000 a month, plus an additional $700,000 for one of the company’s top-of-the-line “ready rooms” installed in a client’s home, yacht or airplane, said Jonathan Frye, chief executive.

While it is difficult to determine how many people are served by this more personalized care, the number of doctors who have moved to this new model has risen fivefold in the last five years. And that raises questions about medical care in America. For those who can afford it, what do they get for their money? Is it worth it? And for the rest of us, who cannot afford this level of care, is it fair and ethical for doctors to be doing this? Or is concierge care contributing to the growing gulf between the wealthy and everyone else?

COSTS AND BENEFITS Concierge medical care is nothing new. In places like Florida, with a high concentration of Medicare patients, some upper-middle-class retirees pay extra fees so they can see a doctor when they need to.

MDVIP, which has 450 concierge doctors in 34 states, charges patients $1,500 to $1,800 a year. Their doctors are each limited to 600 patients, whereas, the company says, most primary care physicians serve at least 2,000 patients. It says appointments with doctors “start on time and last as long as necessary” and can usually be made the same day or the next one. The company’s fee is for the extended care and comprehensive annual physical and wellness plan, but its doctors still bill the patient’s insurance company for procedures.

The international, around-the-clock programs take concierge medicine to a different level. Their primary goal is to offer an extra level of oversight to make sure that participants are getting the proper level of care whenever they need it.

Dr. Miles J. Varn, chief medical officer at PinnacleCare Private Health Advisory, which charges annual fees of $1,500 to $25,000, said the starting point for all patients was a complete review of all health records with an emphasis on finding gaps in care.

“We have physicians who look for omissions of care or deviations from standard care,” Dr. Varn said. “That record travels with them around the world.”

In promoting themselves, the plans say their doctors know each patient’s health conditions intimately and are able to discuss it with another doctor anywhere in the world.

Dr. Daniel Carlin, founder and chief executive of World Clinic, which charges $20,000 to $75,000 a year on average, said he recently had to intervene and stop a patient from getting the wrong procedure. The client was at a hospital in Florida where the doctors wanted to do bypass surgery for a blocked vessel. Dr. Carlin said the proper care was putting in a stent, and the difference was months of pain and recovery for the patient and tens of thousands of dollars for the hospital.

“You’re holding up a shield and saying, ‘We’ll weigh everything before we move forward,’?” Dr. Carlin said. “With the primary care guy gone, the average patient isn’t being treated.”

IS IT WORTH IT? Despite reports about the decline in the number of family physicians and the increase in the hours the remaining ones work, many wealthy people are reluctant to pay extra for health care.